Drug-resistant infections are linked to over a million deaths a year in India. A health crisis compounded by the country’s healthcare inequalities. Dr Gautham and her team are working with rural healthcare providers to better understand the challenges of tackling AMR in these settings – and co-develop innovative solutions.
Rural healthcare provider, Mr. Nikhil Biswas with his son Deepak Biswas at his clinic in the village of Shrirampur in West Bengal, India.
Mr Suparno Munsi, OASIS project
India is home to the world’s largest rural population — an estimated 900 million people.
Across this patchwork of towns, villages and farmlands, access to formal healthcare is extremely limited. Despite the country’s extensive private medical system, most doctors and hospitals are found in cities.
“The moment you leave cities behind, there are no qualified doctors around. People have to travel to the nearest urban centre or government health centre if they want to access a qualified doctor," says Dr Meenakshi Gautham, Assistant Professor at the London School of Hygiene and Tropical Medicine, and Project Leader of One Health Antimicrobial Stewardship for Informal Health Systems (OASIS).
In India, Gautham grew up away from rural life, in the capital city of New Delhi. She trained as a social scientist and then pursued a career in public health. As she began working more closely with rural communities, she was struck by the exceptional contrast in healthcare availability.
“In cities, within a radius of five kilometres, you can find about 50 different private doctors. You have so many options. But the private formal sector is unaffordable [and inaccessible] for the people who live in villages.”
This inequality can have significant impacts on the health of rural populations. For example, infant mortality rate is 46 per thousand live births for rural areas compared to 32 per thousand live births for urban areas.
With limited formal healthcare services, a vast and resourceful network of informal, rural healthcare providers exists to fill the gap.
“When you go into rural India, there are a lot of village doctors,” explains Gautham. “These are health care providers who have not received formal training in health, but they have been trained by doctors as their assistants or technicians.”
After a few years working in the city, informally trained healthcare workers often return home to set up clinics in their villages. Once established, an intricate ecosystem of professional networks, teleconsultation services and training conferences exist to support the informal practices.
“The informal provider is just as trusted and knows just about enough to manage your problem,” says Gautham. “If they have a doubt, they will consult doctors they are connected to. They learn about new drugs and new therapies through pharmaceutical representatives. This mosaic is an amazing entrepreneurial way of managing a lot of people’s health needs. We can't shut them down because the health system will collapse otherwise.”
Rather than fight against this informal system, Gautham’s research hopes to work with it to tackle one of India’s greatest health threats: drug-resistant infections.
Drug-resistant infections are linked to over a million deaths a year in India. A health crisis compounded by the country’s healthcare inequalities.
Since 2016, Gautham and her team at the OASIS project have been working closely with rural communities to better understand the drivers of antibiotic use and the challenges of tackling AMR in rural settings.
Their findings paint a complex picture. Antimicrobial resistance is poorly understood, antibiotic use is difficult to control and disease surveillance data in community settings is almost non-existent.
“It’s a result of the ecosystem in which [the rural healthcare providers] function,” explains Gautham.
Due to a lack of formal medical training, many rural healthcare providers see antibiotics as a cure-all drug. And this misconception extends to the communities they serve. As a result, antibiotics are often dispensed when they are not the appropriate treatment.
“These are communities who need to get better quickly because many of them are daily wage labourers. They cannot take more than a day off work. And they think that giving an antibiotic is the best way of curing a person quickly,” says Gautham.
Another important aspect of Gautham’s research has been to investigate how rural communities and healthcare providers understand the concept of antimicrobial resistance.
“We find that knowledge of what causes [ill] health is very mixed – biomedical concepts blend with traditional medicine,” says Gautham. “And so, their understanding of AMR is limited to some medicines not working because you have taken too many of them.”
Without an understanding of the dangers of AMR, rural healthcare providers aren’t motivated to collect data or monitor antibiotic use. And without the data, it’s difficult to demonstrate the dangers of AMR.
But Gautham and her team have been investigating this for a long time. As well as identifying the problems, they’ve also been working with communities and other important stakeholders in this ecosystem to find solutions.
We’re ensuring research considers the needs and priorities of the most affected communities, so evidence and interventions are acceptable, affordable and accessible in the locations they are most needed.
The OASIS project identified two priority issues to address: there were no suitable antibiotic guidelines for rural healthcare providers and no one was collecting any data.
Gautham and her team knew that the only way to create effective solutions was to co-develop them with people across the informal and formal healthcare ecosystems.
The OASIS team collected years of data from in-depth interviews, surveys and stakeholder consultation groups. They wanted to understand the most common symptoms clinics were facing, how patients were being diagnosed and managed, and which antibiotics were being dispensed and why.
Their findings revealed a clear path forward.
“The [rural healthcare providers] wanted more information about antibiotics, but they wanted it in a flexible format, not where they would have to travel and attend some training program, but something which they could easily manage, like on a mobile phone.”
With support from the Wellcome-funded Trinity Challenge on Antimicrobial Resistance, Gautham and her team are developing the Antibiotic Bandhu App – which means, ‘friend of antibiotics’. This easy-to-use tool will guide users from identifying symptoms to providing first level management for six of the most common illnesses clinics face. Most of which do not require any treatment with antibiotics.
As well as helping reduce inappropriate antibiotic use, the clinics can use the app to record data about which infections they’re treating and whether or not they are dispensing antibiotics in a responsible way.
The OASIS team were winners of the Trinity Challenge on Antimicrobial Resistance. A second funding opportunity focussed on antimicrobial resistance has now launched, supported by Wellcome.
The new challenge is a call for low-cost technology and data-driven solutions to improve access to effective antibiotics in community settings in low- and middle-income countries. A prize fund of up to £1 million is available.
Early feasibility assessments of the guidelines show promising results. “It's like a doctor present near us,” noted one participant.
The OASIS team will be training more rural clinics to use the app and guidelines.
But for the guidelines to be successful, the whole community needs to be on board. Gautham is optimistic that rural healthcare providers are the key:
“A really strong enabling factor is that the future of the community and its health is very important to the rural healthcare providers. If they were to counsel patients to not misuse antibiotics, people would listen to them.”
The OASIS team will also be able to collect and analyse larger sets of data through the app. It will help to inform the practices of the rural providers, and Gautham is hopeful it will be invaluable for local, district and national policymakers too.
“I think it can transform healthcare, the healthcare system, healthcare practices – it can transform our understanding of AMR because there isn't any data coming from the community level. So whatever data we collect it's going to be really, really valuable.”
Assistant Professor, London School of Hygiene and Tropical Medicine
Meenakshi Gautham leads the One Health Antibiotic Stewardship (OASIS) project. She is an interdisciplinary researcher interested in the dynamics of informal health systems, where both formal and informal health actors collaborate to shape healthcare practices. Focusing on antimicrobial resistance (AMR) in community settings, her work uncovers the interactions within these systems, shedding light on health system and policy barriers that impact healthcare delivery and access in resource-constrained contexts.
